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Management of common skin infections
3. Describe the basic management outline for the following conditions: Cellulitis; Impetigo; Fungal infection; Herpes simplex; Herpes zoster; Human PapillomaVirus and Yeast infections 'Cellulitis' *'Identify and manage risk factors' for developing cellullitis, such as lymphoedema, bites, abrasions *'Identify and manage co-morbidities '''which may worsen the cellulitis, or delay recovery, such as diabetes mellitus *'Oral antibiotics in the community are suitable for patients who are otherwise well,' with no systemic symptoms and no uncontrolled co-morbidities *'A short-course (up to 48 hrs) of intravenous antibiotics, administered either in a hospital or a community setting, may be required '''in patients who are either: :: a) systemically well but have a complicating co-morbidity, such as chronic venous insufficiency or :: b) Systemically unwell with no complicating co-morbidities *'Urgently admit a patient who': :: a) Is significantly unwell (e.g. tachycardia, tachypnoea, hypotension, vomiting or acute confusion) :: b) Has septicaemia or a severe life-threatening complication such as necrotising fasciitis :: c) Has severe or rapidly deteriorating cellulitis. Demarcating "tidemarks" of inflammation with a felt-tip pen can give an indication regarding disease progression over time :: d) Is very young (<1 year) or frail :: e) Is immunocompromised :: f) Has significant lymphoedema :: g) Has facial cellulitis (unless very mild) :: h) Has periorbital cellulitis - refer to ophthalmology :: i) Has unstable comorbidities e.g. uncontrolled diabetes :: j) Has a limb threatening infection due to vascular compromise 'Impetigo' Lifestyle advice *'Reassure' patient that impetigo usually heals completely without scarring, and that serious complications are rare *'Advise' patient that: :: a) ' Hygiene ' is important - that avoidance of touching or scratching the infected area is important to stop spread, that washing the area with soapy water prevents re-infection or super-infection, advise handwashing after touching and applying antibiotic cream, and to avoid sharing towels, flannels, clothing and bathwater until the infection has cleared. :: b) Abstain from school or work until the lesions are dry and scabbed over, or until 48 hours after beginning treatment with antibiotic cream :: c) Follow-up if the lesion has not cleared after 7 days *'Treatment:' :: 'a) Bullous infection usually requires treatment with an oral antibiotic '''(flucloxacillin or erythromycin/clarithromycin) :: b) '''Non-bullous infection requires treatment with topical or oral antibiotics *Topical antibiotics such as fusidic acid '(3-4 times daily, for seven days) should be used in '''localized infection. '''Advise patient (or parent) to remove crusted areas by soaking them in hot, soapy water before application *For extensive infection, or for infection in areas where application of a topical antibiotic would be inappropriate, treat with oral antibiotics (as above) 'Fungal Infection NICE Clinical Knowledge Summaries provides excellent management strategy plans for fungal infections of skin nails, feet, and the scalp. 'Herpes simplex' The following advice applies to both type I and Type II infections. Self-care advice Patient should be able to self administer adequate pain relief with over-the-counter paracetamol and NSAIDs. Try to keep infected areas clean in order to prevent secondary infection Avoid sharing items which come into contact with the infected areas, e.g. lip gloss, flannels, towels Try to avoid touching the lesions, except when applying medication, to minimise transmission risk Avoid skin-to-skin contact until lesions are healed. Antivirals Topical aciclovir/penciclovir/idoxuridine can be used to treat mild labial herpes. Genital infections, and severe infections should be treated with a 5-day course of oral aciclovir. Secondary oral antiviral prophylaxis can be given for frequent recurrent episodes. Alternative drug choices include valaciclovir and famciclovir. Ocular herpes is a sight-threatening emergency and should receive immediate specialist treatment. 'Herpes zoster a.k.a. shingles' Lifestyle advice *Keep rash clean and dry to reduce risk of bacterial superinfection *Avoid immunonaive pregnant women, immunocompromised people, and other people's babies under 1 month old *Avoid dressings and topical antibiotics, as they delay rash healing *Seek medical advice if pyrexia develops, as this may indicate bacterial superinfection *Abstain from work, school or daycare whilst rash is weeping and cannot be covered. Prescription of Antivirals Oral antivirals should be started if the patient presents within 72 hours of rash onset, where: *The patient is age 50+ *The patient is under 50 years but has: **Ophthalmic involvement **Immunocompromisation **Non-truncal involvement **Moderate or severe pain **Moderate or severe rash Consider beginning antiviral treatment for up to 1 week after rash presentation if the patient is at risk of developing severe shingles or complications. Always seek specialist advice before prescribing antivirals during pregnancy. Antivirals commonly used in immunocompetent adults include aciclovir, valaciclovir '''and '''famciclovir. '''Prescriptions are given orally, rather than topically. '''Pain management Pain will often be managed adequately with basic analgesia, such as regular paracetamol, NSAIDs, and codeine. If these are not effective, or pain is severe, consider neuropathic pain relief, such as amitriptyline, pregabalin or gabapentin. Seek specialist advice before prescribing strong opioid pain relief. 'Human Papilloma Virus' Conservative management ''' Many warts can resolve spontaneously without medical measures. If the wart is not painful or unsightly, conservative management should be employed, as all treatments have the possibility of side effects. There is some limited evidence that occlusion therapy with duct tape is also effective. '''Salicylic Acid '''is an over-the-counter medication, with higher percentages available on prescription. 70% of warts will resolve within 4 months with daily salicylic acid application. It may cause local skin irritation. '''Cryotherapy '''may be performed using liquid carbon dioxide or nitrogen; and is applied using either cotton wool, or with a specialised spray gun. Freezing causes a painful burning sensation and is poorly tolerated in young children. It may also cause pain, depigmentation, blistering and infection. '''Curettage and cautery '''under local anaesthetic is effective for very large warts, but can leave scarring and warts may recur. '''Podophyllin '''Podophyllin is available in a variety of formulations, including creams, ointments, and solutions. A stronger 15% 'paint' preparation should only be applied by trained health practitioners, as it may cause chemical burns. It should not be used on many warts simultaneously due to the risk of toxicity, and should never be used in pregnancy. '''Imiquimod '''is an immunomodulator, stimulating cytokine production at the site of application. 3 times per week treatment should continue until the warts resolve or for a maximum of 16 weeks. Local irritation and inflammation can be severe, especially on mucosal surfaces '''Further specialised treatments are available, consider referring to a specialist where warts are located on the face, or refractory to treatment. 'Yeast Infections' As yeasts are a type of fungus, yeast infections can be treated with common antifungal preparations. '''''Candida ''Candida ''responds to clotrimazole, miconazole and nystatin. These drugs are available in many formulations including pastilles, mouthwashes, lozenges, oral gels, pessaries, lotions, creams and systemic tablets. Choice of treatment depends on location and severity of infection, and on patient preference.